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F.(I PR(IGRAM C(INR555AWn 11niq TANKS UNDERGROUND STORAGE TANKS - TANK PAGE 2 Pae of Vt.PIPING.CO.STRUCTION(ch«keitthata Iv - - : - UNDERGROUND PIPING ABOVEGROUND PIPING SYSTEM TYPE 1.PRESSURE -❑2.SUCTION ❑3.GRAVITY 456, E(1.PRESSURE ❑2.SUCTION , ❑3.GRAVITY 459. CONSTRUCTION/ I.SINGLE WALL ❑3.LINED TRENCH [199.OTHER 460. 0 1.SINGLE WALL ❑95.UNKNOWN 462. MANUFACTURER 2.DOUBLE WALL , [195.UNKNOWN 2.DOUBLE WALL ❑99.OTHER MANUFACTURER 461. MANUFACTURER 463. [11.BARE STEEL ❑6.PRP COMPATIBLE W/100%METHANOL [:11.BARE STEEL ❑6.FRP COMPATIBLE W/100%METHANOL ❑2.STAINLESS STEEL.. Q 7.GALVANIZEDSTEEL t:- [12.STAINLESS STEEL 1 ❑7.GALVANIZED STEEL [13.PLASTIC COMPATIBLE WITH CONTENTS El 95.UNKNOWN ❑3.PLASTIC COMPATIBLE W/CONTENTS ❑8.FLEXIBLE(HDPE) (7 99.OTHER P(4.FIBERGLASS ❑S.FLEXIBLE(HDPE) ❑99.OTHER ❑4.FIBERGLASS ❑9.CATHODIC PROTECTION ❑5.STEEL W/COATING ❑9.CATHODIC PROTECTION 464. [15.STEEL W/COATING ❑95.UNKNOWN 465. RIFING:LEAK DETECTION(Check all that apply)(A darn tion ofthc monkorin shell be submittcd to the lural -etc ) UNDERGROUND PIPING ABOVEGROUND PIPING SINGLE WALL PIPING 466. SINGLE WALL PIPING 467. P URIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all dal apply): ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PUMP Ej 1. ELECTRONIC LINE LEAK DETECTOR 3.0 GPH TEST WITH AUTO PIMP SHUT-OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION SHUT OFF FOR LEAK,SYSTEM FAILURE,AND SYSTEM DISCONNECTION +AUDIBLE AND VISUAL ALARMS. +AUDIBLE AND VISUAL ALARMS [12. MONTHLY 0.2 GPI{TEST - ; I 0 2, MONTHLY 0.2 GPH TEST ❑3. ANNUAL INTEGRITY TEST(0.1 GPH) ❑3, ANNUAL INTEGRITY TEST(0.1 GPH) A [34. DAILY VISUAL CHECK CONVENTIONAL SUCTION SYSTEMS '�. CONVENTIONAL SUCTION SYSTEMS(Check all that apply) ❑5. DAILY VISUAL MONITORING OF PUMPING SYSTEM+TRIENNIALPINING 5. DAILY VISUA INTEGRITY TEST(0.)GPH) L MONITORING OF PIPING AND PUMPING SYSTEM ' SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): ❑6. TRIENNIAL INTEGRITY TEST(0.1 GPH) E17. SELF MONITORING SAFE SUCTION SYSTEMS(NO VALVES IN BELOW GROUND PIPING): GRAVITY FLOW _ El 7. SELF MONITORING ❑9. BIENNIAL INTEGRITY TEST(0.1 GPH) GRAVITY FLOW(Check all that apply): [38. DAILY VISUAL MONITORING.. [39. BIENNIAL INTEGRITY TEST(0.1 GPH) SECONDARILY CONTAINED PIPING SECONDARILY CONTAINED PIPING PRESSURIZED PIPING(Check all that apply): PRESSURIZED PIPING(Check all that apply): " 10. CONTINUOUS TURBINE SUMP SENSOR WITH AUDIBLE AND VISUAL 10. CONTINUOUS TURBINE SUMP SENSOR NJ= AUDIBLE AND VISUAL ALARMS AND(Check one) ALARMS AND(Check one) [f a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑a. AUTO PUMP SHUT OFF WHEN A LEAK OCCURS ❑It. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM ❑b. AUTO PUMP SHUT OFF FOR LEAKS,SYSTEM FAILURE AND SYSTEM DISCONNECTION - DISCONNECTION ❑c. NO AUTO PUMP SHUT OFF Qc. NO AUTO PUMP SHUT OFF 11. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST)WITH FLAW SHUT 11. AUTOMATIC LEAK DETECTOR OFF OR RESTRICTION ,9 12.ANNUAL INTEGRITY TEST(0.1 GPH) ❑12. ANNUAL INTEGRITY TEST(0.1 GPH) SUCFIONIGRAVITY SYSTEM SUCTION/GRAVITY SYSTEM [313. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS ❑13. CONTINUOUS SUMP SENSOR+AUDIBLE AND VISUAL ALARMS EMERGENCY GENERATORS ONLY(Check all that apply) EMERGENCY GENERATORS ONLY(Check all that apply) [114. CONTINUOUS SUMP SENSOR WITHOUT AUTO PUMP SHUT OFF ❑14. CONTINUOUS SUMP SENSOR WITHOUT 4UTO PUMP SHUT OFF AUDIBLE AND VISUAL ALARMS AUDIBLE AND VISUAL ALARMS [115. AUTOMATIC LINE LEAK DETECTOR (3.0 GPH TEST) WITHOUT FLOW I]15. AUTOMATIC LINE LEAK DETECTOR(3.0 GPH TEST) SHUT OFF OR RESTRICTION ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) ❑16. ANNUAL INTEGRITY TEST(0.1 GPH) 17. DAILY VISUAL CHECK [117. DAILY VISUAL CHECK C' VIII.DISPENSER CONTAINMENT DISPENSER CONTAINMENT 468. 1. FLOAT MECHANISM THAT SHUTS OFF SHEAR VALVE 4. DAILY VISUAL CHECK 469. DATE INSTALLED [12. CONTINUOUS DISPENSER PAN SENSOR+AUDIBLE AND VISUAL ALARMS [15. TRENCIULINER MONITORING ❑3. CONTINUOUS DISPENSER PAN SENSOR WITH AUTO SHUT OFF FOR [16. NONE DISPENSER+AUDIBLE AND VISUAL ALARMS ' - IX.OWNER/OPERATOR SIGNATURE .. - ... I certify that the information provided rein is true and ac rate to the best of my knowledge. SIGNATURE OF OWNEWOPERATORJ. n/ DATE: 09 .L -0 ,6 470. W V NAME OF OWNER/OPERATOR(print): TITLE OF OWNER/OPERATOR: 472 _S'mite7e,0 -9N4h• 1910•--ern MIA+Azrl Pmnll Nmnber(Agency use only) 473. 1 Permit Approved By(Agency use only) 474. Pernril Expitation Dam(Agency tae only) 48. UPCF bw(wrc-6(1/99)-3/4 http://3vww.unidomorg Rev.02/16/00